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United States Department  of Veterans Affairs

Substance Abuse Screening - Manual Instructions

Thank you for taking this brief screen about alcohol, tobacco products and other drugs. The following questions will ask you about your experience of using these substances across your lifetime and in the past three months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in the form of pills.

Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). For this screen, do not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please answer the questions accordingly. While we are also interested in knowing about your use of various illicit drugs, please be assured that information on such use will be treated as strictly confidential. This entire screening is processed on this local computer. No information is collected, stored or sent over the Internet. To ensure complete privacy, exit your web browser after completing this screening.

Instructions on scoring and interpreting your results are located after the final question.

There is also an interactive version of this tool.

Q1. In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY) Tobacco products, alcoholic beverages, cannabis, cocaine, stimulants, inhalants, sedatives/hypnotics, hallucinogens, opioids, and �other drugs�. Answers: No, Yes

If you answered "Yes" to any of these items, answer Question 2 for each substance ever used.

Q2: In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)? Answers: Never, Once or Twice, Monthly; Weekly; Daily or Almost Daily

If you answered "Never" to all items in Question 2, skip to Question 6.

If you used any substances in Question 2 in the previous three months, continue with Questions 3, 4 & 5 for each substance used.

Q3: During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)? Answers: Never, Once or Twice, Monthly; Weekly; Daily or Almost Daily

Q4: During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems? Answers: Never, Once or Twice, Monthly; Weekly; Daily or Almost Daily

Q5: During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)? Answers: Never, Once or Twice, Monthly; Weekly; Daily or Almost Daily

Do not answer this question for tobacco products.

Answer Questions 6 & 7 for all substances ever used (i.e. those answered "Yes" in Question 1)

Q6: Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC.)? Answers: No, Never; Yes, in the past 3 months; Yes, but not in the past 3 months.

Q7: ave you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)? Answers: No, Never; Yes, in the past 3 months; Yes, but not in the past 3 months.

How to score your answers.

Now that you have answered all of the questions, you will need to score your answers.

For questions 2 - 5, each "Never" answer has a value of 0. Each "Once or Twice" answer has a value of 3. Each "Monthly" answer has a value of 4. Each "Weekly" answer has a value of 5. Each "Daily or Almost Daily" answer has a value of 6.

For questions 6 & 7, each "No, Never" answer has a value of 0. Each "Yes, in the past 3 months" answer has a value of 6. Each "Yes, but not in the past 3 months" answer has a value of 3.

Total all your answer scores to determine your screening result for each substance.

Results

For alcohol, a score between 0 and 10 = Low Risk. A score between 11 and 26 = Moderate Risk. A score of 27 or more = High Risk.

For all other substances, a score between 0 and 3 = Low Risk. A score between 4 and 26 = Moderate Risk. A score of 27 or more = High Risk.

What do your scores mean?

Low: You are at low risk of health and other problems from your current pattern of use.

Moderate: You are at risk of health and other problems from your current pattern of substance use.

High: You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use and are likely to be dependent.

This screen is not designed to provide a comprehensive assessment or diagnosis of substance abuse. Only a qualified physician or mental health provider can provide a complete assessment and diagnosis of substance abuse. Only a qualified physician or mental health professional can differentiate symptoms of substance abuse from other medical conditions. Only a qualified physician or mental health provider can prescribe appropriate treatment for substance abuse or other medical conditions.

If you are concerned about any illness, regardless of what the screening test shows, you should seek further evaluation from your physician. If you are concerned that you may have a medical emergency or are having thoughts of harming yourself or someone else, call 911, or go immediately to the nearest hospital Emergency Room for an evaluation.

You can print this page for your own records or to give to your physician or a mental health care provider.

Substance Abuse Screening (ASSIST) - Instructions

Thank you for taking this brief screen about alcohol, tobacco products and other drugs. The following questions will ask you about your experience of using these substances across your lifetime and in the past three months. These substances can be smoked, swallowed, snorted, inhaled, injected or taken in the form of pills.

Some of the substances listed may be prescribed by a doctor (like amphetamines, sedatives, pain medications). For this screen, do not record medications that are used as prescribed by your doctor. However, if you have taken such medications for reasons other than prescription, or taken them more frequently or at higher doses than prescribed, please answer the questions accordingly. While we are also interested in knowing about your use of various illicit drugs, please be assured that information on such use will be treated as strictly confidential. This entire screening is processed on this local computer. No information is collected, stored or sent over the Internet. To ensure complete privacy, exit your web browser after completing this screening.

If you have problems accessing this tool, there is also text-only version.

1. In your life, which of the following substances have you ever used? (NON-MEDICAL USE ONLY) No Yes
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other
2. In the past three months, how often have you used the substances you mentioned (FIRST DRUG, SECOND DRUG, ETC)? Never Once or Twice Monthly Weekly Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other
3. During the past three months, how often have you had a strong desire or urge to use (FIRST DRUG, SECOND DRUG, ETC)? Never Once or Twice Monthly Weekly Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other
4. During the past three months, how often has your use of (FIRST DRUG, SECOND DRUG, ETC) led to health, social, legal or financial problems? Never Once or Twice Monthly Weekly Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other
5. During the past three months, how often have you failed to do what was normally expected of you because of your use of (FIRST DRUG, SECOND DRUG, ETC)? Never Once or Twice Monthly Weekly Daily or Almost Daily
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other
6. Has a friend or relative or anyone else ever expressed concern about your use of (FIRST DRUG, SECOND DRUG, ETC.)? No, Never Yes, in the past 3 months Yes, but not in the past 3 months
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other
7. Have you ever tried and failed to control, cut down or stop using (FIRST DRUG, SECOND DRUG, ETC.)? No, Never Yes, in the past 3 months Yes, but not in the past 3 months
a. Tobacco products (cigarettes, chewing tobacco, cigars, etc.)
b. Alcoholic beverages (beer, wine, spirits, etc.)
c. Cannabis (marijuana, pot, grass, hash, etc.)
d. Cocaine (coke, crack, etc.)
e. Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)
f. Inhalants (nitrous, glue, petrol, paint thinner, etc.)
g. Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc.)
h. Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)
i. Opioids (heroin, morphine, methadone, codeine, etc.)
j. Other

Your answers to the anonymous and confidential screen for substance abuse are listed below for your review.

Substance Score
a. Tobacco products 0
b. Alcoholic beverages 0
c. Cannabis 0
d. Cocaine 0
e. Amphetamine type stimulants 0
f. Inhalants 0
g. Sedatives or Sleeping Pills 0
h. Hallucinogens 0
i. Opioids 0
j. Other 0

What do your scores mean?
Low: You are at low risk of health and other problems from your current pattern of use.
Moderate: You are at risk of health and other problems from your current pattern of substance use.
High: You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use and are likely to be dependent

This screen is not designed to provide a comprehensive assessment or diagnosis of substance abuse. Only a qualified physician or mental health provider can provide a complete assessment and diagnosis of substance abuse. Only a qualified physician or mental health professional can differentiate symptoms of substance abuse from other medical conditions. Only a qualified physician or mental health provider can prescribe appropriate treatment for substance abuse or other medical conditions.

If you are concerned about any illness, regardless of what the screening test shows, you should seek further evaluation from your physician. If you are concerned that you may have a medical emergency or are having thoughts of harming yourself or someone else, call 911, or go immediately to the nearest hospital Emergency Room for an evaluation.

You can print this page for your own records or to give to your physician or a mental health care provider.

Your answers to the anonymous and confidential screen for substance abuse are listed below for your review.

Substance Score Risk Level
a. Tobacco products 0
0-3 Low
4-26 Moderate
27+ High
b. Alcoholic beverages 0
0-10 Low
11-26 Moderate
27+ High
c. Cannabis 0
0-3 Low
4-26 Moderate
27+ High
d. Cocaine 0
0-3 Low
4-26 Moderate
27+ High
e. Amphetamine type stimulants 0
0-3 Low
4-26 Moderate
27+ High
f. Inhalants 0
0-3 Low
4-26 Moderate
27+ High
g. Sedatives or Sleeping Pills 0
0-3 Low
4-26 Moderate
27+ High
h. Hallucinogens 0
0-3 Low
4-26 Moderate
27+ High
i. Opioids 0
0-3 Low
4-26 Moderate
27+ High
j. Other 0
0-3 Low
4-26 Moderate
27+ High

What do your scores mean?
Low: You are at low risk of health and other problems from your current pattern of use.
Moderate: You are at risk of health and other problems from your current pattern of substance use.
High: You are at high risk of experiencing severe problems (health, social, financial, legal, relationship) as a result of your current pattern of use and are likely to be dependent

This screen is not designed to provide a comprehensive assessment or diagnosis of substance abuse. Only a qualified physician or mental health provider can provide a complete assessment and diagnosis of substance abuse. Only a qualified physician or mental health professional can differentiate symptoms of substance abuse from other medical conditions. Only a qualified physician or mental health provider can prescribe appropriate treatment for substance abuse or other medical conditions.

If you are concerned about any illness, regardless of what the screening test shows, you should seek further evaluation from your physician. If you are concerned that you may have a medical emergency or are having thoughts of harming yourself or someone else, call 911, or go immediately to the nearest hospital Emergency Room for an evaluation.

You can print this page for your own records or to give to your physician or a mental health care provider by pressing CTRL+P or by going to File>Print in your browser's menu.


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